JP5502055B2 - Intermediary device for nursing care benefit billing procedures - Google Patents

Description

  The present invention is an intermediary device for a nursing care benefit billing procedure that mediates between a nursing care benefit billing procedure that is interposed between a terminal that bills a nursing care benefit cost and a terminal that accepts a claim for nursing care benefit cost. About.

  It is interposed between the terminal of the side that makes a claim for care benefits (for example, a care establishment such as a service establishment or a support establishment) and the terminal that accepts the claim for care benefits (for example, the National Health Insurance Federation) 2. Description of the Related Art “Medical benefit request procedure mediation apparatus” that mediates care benefit request procedures has been known.

  In this kind of intermediary device, each nursing care facility side terminal is connected via the Internet, which is made into a virtual private line by encryption technology using ID and password, The terminal is connected via an ISDN line so that a predetermined transmission / reception relay function is realized. Note that the ISDN line connecting the intermediary device and a terminal such as the National Health Insurance Federation will be replaced with a similar virtual private line Internet in the near future.

  Here, the “predetermined transmission / reception relay function” is a function for transmitting information (for example, a nursing care benefit bill / specification file) coming from a terminal on the nursing care establishment side to a terminal on the side of the National Health Insurance Federation and the like. Information stored in the database and sent from terminals such as the National Health Insurance Federation (for example, billing statement / benefit management form return (hold) list, nursing insurance examination decision increase / decrease table, and nursing insurance examination increase / decrease unit A number notification slip, etc.) and stored in a predetermined database, and in response to a browsing request from the terminal on the care facility side, browsing data obtained by processing the browsing requested information for browsing This is a function that sends it to the terminal of the nursing care facility that is the request source.

  Because this transmission / reception relay function exists, each nursing care establishment can communicate with a terminal such as the National Health Insurance Federation individually without introducing an ISDN line, and the terminal such as the National Health Insurance Federation can use a relatively low usage fee. Can be connected, and the labor and cost of introducing an ISDN line individually can be reduced.

  By the way, in addition to the transmission / reception relay function described above, this type of mediation apparatus is provided with various service functions for user support, and the usability of these service functions is one of the selling points. .

  Conventionally, the nursing care benefit billing information transmitted to the terminal of the National Health Insurance Federation and the examination result information transmitted from the terminal of the National Health Insurance Federation or the like are taken in through the manual operation of the operator and accumulated. Based on the information, the billing information is managed individually, and this is displayed on the screen as necessary, so that it is possible to reliably collect the nursing care benefits that could not be stored for return. An information management apparatus is known (see Patent Document 1).

JP 2002-288345 A

  In the management device for the above-mentioned nursing care benefit billing information, the taken care benefit billing information (nursing benefit bill / details file) and examination result information (billing statement / benefit management slip return (pending)) Based on a list, a care insurance examination decision increase / decrease table, and a care insurance examination increase / decrease unit number notification vote, etc., the “individual billing information table” shown in FIGS. 4, 6, and 10 of the same document is generated. .

  As is clear from these figures, the horizontal columns of this “individual billing information table” include “Provision Month”, “Billing Month”, “Service Type”, “Number of Units”, “Number of Billing”, It is pre-assigned to “Examination results” and “Processing (situation)”, and each column in the vertical direction identifies individual insured persons (Taro Ueda, Goro Yoshida) identified by the insurer number and the insured number. And so on).

  When registering into the “Individual Request Information Table”, the relationship between the “examination result” and the “processing (situation)” paired with the “examination result” is as follows: In the same manner, “pass”: “scheduled to pay”, “hold”: “waiting”, “assessment”: “re-billing (re-billing by the number of units after assessment)”, “return”: “ "Reclaim (with error, correct and reclaim)", "Restoration": "Scheduled to pay" (see description on page 7, column 12, lines 3 to 10).

  If the insurer number, the insured number, the service provision month, the service type are the same and the billing month is different, the billing count of the data with the new billing month is registered as the recent data billing count + 1 ( (See the description on page 7, column 11, lines 25 to 28).

  The “Individual Billing Information Table” holds information as a history, but the Individual Billing Information Screen displays the latest information that meets the conditions of the condition search screen (the number of billing is the oldest number). (Refer to description on page 8, column 13, lines 7 to 10).

  However, in the care benefit billing information management apparatus having the above-described configuration, the determination of “processing (situation)” is made based only on the “examination result” from the National Health Insurance Federation. Since re-billing information from the office is not considered at all (see FIGS. 4, 6, and 10 of the same publication), the “examination result” is “return” and the determination result of “processing (situation)” is “ In the case of “re-claim”, even if a re-claim is made for the nursing care benefit expense claim, the judgment result of “processing (situation)” is “until the“ examination result ”is changed by the National Health Insurance Federation. “Recharge” is maintained, and the guidance display on the screen is maintained in the content requesting “recharge” despite the recharge. Therefore, in order to change the guidance display on the screen from “Recharge” to “Standby” in response to the recharge, it is necessary to manually correct the individual charge information manually. (See paragraph 0047 of the same document).

  In addition, in the management device described above, since the examination result information is not sent to the terminal on the side of the care establishment via its own, like an intermediary device having a transmission / reception relay function, In order to obtain accurate judgment results (“pending”, “return”, “pending recovery”, etc.) regarding “processing (situation)”, it is necessary to manually register the examination result information necessary for it each time through manual operation. As a result, the reliability of the determination result depends on the user's registration operation of the examination result information. If the registration operation is neglected or the operation is incorrect, the accurate determination result regarding “processing (situation)” Cannot be obtained.

  The present invention has been made paying attention to the above-mentioned problems, and the purpose of the present invention is to determine whether a “return” or “hold” is made in the examination by the National Health Insurance Federation regarding any nursing care benefit claim. When accreditation is made, or when a nursing care facility notices an "error" for any nursing care benefit request project, it automatically generates a status where the nursing care benefit request project is "unsupported" Accordingly, an object of the present invention is to provide an intermediary device for a nursing care benefit billing procedure that can surely prompt the user to respond to the matter.

  Other objects and operational effects of the present invention will be easily understood by those skilled in the art by referring to the following description of the specification.

  It is considered that the technical problem of the present invention can be solved by an intermediary device for a nursing care benefit request procedure having the following configuration.

  That is, the intermediary device of the nursing care benefit billing procedure of the present invention is a device that is interposed between the terminal of the nursing care establishment that requests the nursing care cost and the terminal of the side of the National Health Insurance Federation that accepts the claim of the nursing care cost. The terminal is connected to the terminal of the nursing care establishment side via a network system, and the terminal of the side of the National Health Insurance Federation is connected via an ISDN or other network system to a predetermined This implements a transmission / reception relay function.

  The predetermined transmission / reception relay function is to transmit and store information arriving from the terminal of the nursing care establishment side to a terminal of the National Health Insurance Federation or the like and sent from the terminal of the National Health Insurance Federation or the like. Receiving and storing information to be received, and in response to a browsing request from the terminal on the side of the nursing care facility, the nursing care facility that requests the browsing data formed by processing the requested information for browsing It is a function to send to the terminal on the side.

  Each time the device receives a return / holding data related to any nursing care benefit billing item from the terminal of the National Health Insurance Federation or the like, the device sets a corresponding status flag of the nursing care benefit billing case related to the return / holding data to “Not yet”. "Responsibility", and after that, re-billing data will come from the nursing care facility side terminal or a re-examination decision notification will come from the terminal of the National Health Insurance Federation etc. regarding the nursing care benefit billing case Waiting for either of the re-billing data or the notice of re-examination decision, and automatically clearing the “unsupported” registration of the corresponding status flag of the nursing care benefit claim request A first corresponding state flag control function is further included.

  Furthermore, in the transmission / reception relay function, in response to an unsupported item browsing request for return / pending disposal coming from the terminal on the nursing care facility side, “unsupported” of the return / pending disposal corresponding status flag is used as a key. A first browsing data generation / transmission function is included that generates browsing data processed so that a list of searched nursing care benefit billing cases is displayed and sends it to the terminal of the nursing care facility that is the request source. ing.

  According to such a configuration, by the first response status flag control function, the response status flag for return / pending disposal is not only received from the terminal of the National Health Insurance Federation or the like, but also from the terminal of the care establishment side. Since it is also controlled by the information, the status that the nursing care benefit claim related to the return / pending disposal is not supported is surely reflected in the status “unsupported” of the corresponding response status flag. On the other hand, the first browsing data generation / sending function sets “unsupported” in the return / holding disposal status flag in response to an unsupported item browsing request for returning / holding disposal coming from the terminal of the nursing care establishment. The browsing data processed so that the nursing care benefit billing cases searched as a key are displayed as a list is generated and sent to the terminal of the nursing care establishment as a request source. Therefore, if you make a browsing request regarding an unsupported item that is not returned or suspended at the terminal of the nursing care facility, a list of the nursing care benefit billing cases related to “Unsupported” will be displayed on the screen of the terminal. Therefore, it is possible to prevent a situation in which the repaid or suspended nursing care benefit claim project is left unattended for a long period of time and accrued.

  In a preferred embodiment, each time the device receives an error determination notification related to any nursing care benefit claim request from a terminal of the National Health Insurance Federation or the like, the device responds to the care benefit request claim related to the error determination notification. Register the status flag as “Not supported”, and wait for the re-billing data from the terminal of the nursing care facility regarding the long-term care benefit billing case, and wait for the re-billing data. In addition, it may further include a second response status flag control function that automatically deletes the “unsupported” registration of the response status flag of the care benefit billing case.

  In addition, in the transmission / reception relay function, in response to a request for browsing a non-corresponding case of erroneous data coming from the terminal of the nursing care facility side, an error that has been retrieved using “unsupported” in the corresponding status flag of the erroneous data as a key. It further includes a second browsing data generation / sending function that generates browsing data processed so as to display a list of unsupported long-term care benefit billing cases and sends it to the terminal of the nursing care facility that is the request source You may go out.

  According to such a configuration, the second correspondence state flag control function allows the erroneous state correspondence state flag to be determined not only by information from the terminal of the National Health Insurance Federation or the like, but also by information from the terminal of the nursing care establishment side. Therefore, the status that the nursing care benefit billing case related to the error data is not supported is surely reflected in the status “unsupported” of the corresponding response status flag. On the other hand, the second browsing data generation / transmission function performs a search using “unsupported” in the handling status flag of the erroneous data as a key in response to an unsupported item browsing request for erroneous data arriving from the terminal on the care establishment side. The browsing data processed so as to display a list of the nursing care benefit cost claim cases that do not correspond to errors is generated and sent to the terminal on the nursing care facility side that is the request source. Therefore, if you make a browsing request regarding an unsupported item for error data on the terminal of the nursing care facility side, the list of the nursing care benefit billing cases related to “Unsupported” will be displayed on the screen of the terminal. By promptly promoting the response to the case, it is possible to prevent a situation in which the nursing care benefit billing case relating to the erroneous data is left unattended for a long time and accrued.

  In a preferred embodiment, in the list display of the long-term care benefit billing cases, a determination result obtained by automatically determining a determination result obtained by the system according to a predetermined determination criterion on the status of each claim item is displayed. When a display column is provided for each billing item display line and a display corresponding to “confirmation required” is performed in the determination result display column, the entire billing item display line related to the “confirmation required” has a predetermined color or You may make it be a specific display state with a brightness | luminance.

  According to such a configuration, in the list display of the long-term care benefit request cases related to “unsupported”, the long-term care benefit cost claim case related to “confirmation required” is clearly shown to the user based on the determination criterion on the system side. Therefore, it is possible to prompt a quicker response.

  In a preferred embodiment, in the list display of the long-term care benefit billing cases, the comprehensive judgment result for displaying the judgment result obtained by the operator comprehensively judging the status of each billing case by a manual operation in the menu method. A display field is provided for each billing item display line, and the initial display state of the comprehensive judgment result display field is linked to the display state of the system judgment result display field, which is equivalent to “consumption completed” by manual operation. When the display is changed to, the specific display state relating to the billing matter display line may be canceled.

  According to such a configuration, for the nursing care benefit billing cases for which necessary confirmation work has been completed in accordance with the “need confirmation” display in the system determination result display field, the display in the comprehensive determination result display field can be manually cleared. If it is changed to a display corresponding to “completed”, the specific display state related to the billing matter display line is canceled, so that the confirmation end matter and the unconfirmed matter are identified based on the presence or absence of the specific display state of the display line, Confirmation work can be performed efficiently.

  In a preferred embodiment, when the initial display state of the comprehensive determination result display field is changed to a display corresponding to “consumption completed” by manual operation, “Unsupported” registration may also be canceled.

  According to such a configuration, for the nursing care benefit billing cases for which necessary confirmation work has been completed in accordance with the “need confirmation” display in the system determination result display field, the display in the comprehensive determination result display field can be manually cleared. If it is changed to the display corresponding to “Completed”, the “Non-supported” registration of the response status flag of the nursing care benefit billing project related to the billing project display line will also be canceled. As a result of being excluded from the unsupported search target, it is possible to avoid the list of confirmed matters being repeatedly displayed.

  In a preferred embodiment, in the list display of the long-term care benefit billing cases, a changed login ID display column is provided for each billing case display line, and the initial display state of the comprehensive determination result display column is manually operated. When the display is changed to the display corresponding to “completion completed”, the login ID of the user who performed the changing operation may be displayed in the changed login ID display field.

  According to such a configuration, by automatically displaying the login ID of the user who performed the change operation in the change login ID display column, it is possible to trace the operator related to the change operation later, It is possible to prevent a change operation from being performed.

  According to the present invention, when a browsing request regarding an unsupported case of return / pending is made at a terminal on the side of a nursing care establishment, a list of care benefit claim claims related to true “unsupported” is displayed on the screen of the terminal. Because it is displayed, by prompting the user to respond to the case, it is possible to prevent a situation where the repaid or suspended care benefit claim request case is left unattended for a long time and accrued. be able to.

It is a system configuration figure of the mediation device concerning the present invention. It is explanatory drawing (the 1) of the process for implement | achieving a transmission / reception relay function. It is explanatory drawing (the 2) of the process for implement | achieving a transmission / reception relay function. It is explanatory drawing (the 3) of the process for implement | achieving a transmission / reception relay function. It is explanatory drawing of the process for implement | achieving a 1st corresponding | compatible state flag control function. It is explanatory drawing of the process for implement | achieving a 2nd corresponding | compatible state flag control function. It is explanatory drawing which shows the example of a display of the unsupported return / pending case list (whole) for every establishment. FIG. 8 is an enlarged view of the unsupported return / pending case list (left side portion) shown in FIG. 7. FIG. 8 is an enlarged view of the unsupported return / holding case list (right side portion) shown in FIG. 7. It is explanatory drawing which shows the example of a display of the non-corresponding return / pending case list (whole) for every group. It is explanatory drawing which shows the example of a display of the malpractice list (whole) for every establishment.

  Hereinafter, a preferred embodiment of an intermediary device (hereinafter simply referred to as an “intermediary device”) for a care benefit billing procedure according to the present invention will be described in detail with reference to the accompanying drawings.

  A system configuration diagram of an intermediary device according to the present invention is shown in FIG. As shown in the figure, the intermediary device 10 includes terminals 20-1 to 20-n on the side (for example, a care establishment such as a service establishment or a support establishment) that makes a claim for care payment costs and the care payment costs. It intervenes between the terminal 30 on the side (for example, the National Health Insurance Federation, etc.) that accepts the request for the nursing care benefit expenses and mediates. In addition, the intermediary device 10 functions as an ASP server, and the terminals 20-1 to 20-n on the care establishment side also function as clients. Various functions can be provided from the intermediary device 10 according to the fee.

  The mediating device 10 is not shown for hardware reasons when viewed in terms of hardware, but includes an external storage device such as a hard disk, a semiconductor memory such as a ROM or a RAM, a CPU constituted by a microprocessor or a dedicated LSI. Via the ISDN line between the included computer and the terminal 30 on the side of the National Health Insurance Federation or the like, the first communication device that controls transmission / reception via the network between the terminals 20-1 to 20-n on the care establishment side And a second communication device that performs transmission and reception.

  In addition, in the intermediary device 10, a transmission / reception relay function 1, a progress stage management function 2 such as a billing procedure, a transmission information pre-transmission check function 3, 1, a correspondence status flag control function 4, a billing omission prevention function (warning mail distribution function) 5, a second correspondence status flag control function 6, a data management function 7, and a corporate headquarters management support function 8 are incorporated.

  In addition, the database management unit 9 includes information on members (corporations) that can use the system (for example, the name of each corporation that is a member, the login ID and password of the corporation, one or more nursing care businesses operated by the corporation). Member master 9a which is a master storing the business, etc., and business which is a master storing business information for each member who can use this system (for example, the name of each business, the login ID and password of the business) When a plurality of offices operated by a site master 9b or member (corporate) are grouped into one or more groups, the relationship between each group name and one or more offices belonging to the group, etc. The establishment group master 9c, which is the master storing the information, the National Health Insurance claim data 9d, which is the information requested for transmission to the National Health Insurance Federation, and the information requested for transmission to the National Health Insurance Federation. On the other hand, the National Health Insurance return data 9e which is the information that returned the result of examination by the National Health Insurance Federation, Claim Management Data (Return) 9f which is the information extracted from the return information of the National Health Insurance return data, the transmission request processing to the National Health Insurance Federation Receivables management data (billing) 9g, which is the information extracted from the latest examination date of the minutes, error data (returning) 9h, which is information extracting the error information from the National Health Insurance return data, and transmission request processing to the National Health Insurance Federation The error data (billing) 9i, which is information obtained by extracting the latest examination date and time among the minutes, is stored.

  The intermediary device 10 is connected to the individual nursing care facility side terminals 20-1 to 20-n via the Internet that is made into a virtual private line by an encryption technique using an ID and a password. The terminal 30 on the other side is connected via an ISDN line, and thereby, a predetermined transmission / reception relay function is realized. It should be noted that the ISDN line connecting the intermediary device 10 and the terminal 30 such as the National Health Insurance Federation is scheduled to be replaced in the near future by a similar virtual private line Internet.

  Here, the “predetermined transmission / reception relay function” means that information (for example, a nursing care benefit bill statement file) coming from the terminals 20-1 to 20-n on the nursing care establishment side is a terminal on the side of the National Health Insurance Federation or the like. 30 (see National Health Insurance claim data 9d) and information sent from the terminal 30 such as the National Health Insurance Federation (for example, billing statement / benefit management slip return (hold) list, nursing insurance Receive and save examination decision increase / decrease table and nursing insurance examination increase / decrease unit number notification slip etc.) (refer to National Health Insurance return data 9e), and request for browsing from terminals 20-1 to 20-n on the nursing care establishment side Correspondingly, it is a function of sending the browsing data obtained by processing the requested information for browsing to the terminal on the nursing care facility side that is the request source.

  The presence of this transmission / reception relay function enables each nursing care establishment to connect to a terminal on the side of the National Health Insurance Federation with a relatively low usage fee without introducing an ISDN line individually. This saves the labor and cost of installing an ISDN line.

  Next, explanatory diagrams (No. 1 to No. 3) showing an example of processing for realizing the transmission / reception relay function are shown in FIGS.

  FIG. 2 shows a series of steps executed by transmitting billing data CSV (meaning billing data in CSV format) by a predetermined operation on the National Health Insurance Federation transmission screen in each of the business site terminals 20-1 to 20-n. Processing is shown. That is, each of the business establishment side terminals 20-1 to 20-n uses the support software provided by the National Health Insurance Federation or the commercially available support software to create the claim data D1 that is a CSV file related to the nursing care benefit expenses, A connection is made with the mediation apparatus 10 which is an ASP using a predetermined ID and password, and then the billing data CSV is transmitted by a predetermined operation on the national insurance continuous transmission screen of the business site terminals 20-1 to 20-n. (Step 101).

  Then, the billing data D1 is received and stored in the database 9 (see National Health Insurance claim data 9d) by the action of the communication device (not shown) of the intermediary device 10 with respect to the business office, and is attached to the data D1. The transmission request command (not shown) is stored in time series in a request table (having a FIFO function) TB1 from the screen.

  On the other hand, the mediating apparatus 10 checks whether there is a request from the screen at a predetermined minute time interval (for example, every 3 seconds) via the request table TB1, and determines the oldest request command that has not been processed. A series of processes (steps 202 to 207) are repeatedly executed every time the information is acquired (step 201).

  Assuming that the transmission request command from the office side terminal is acquired in the process of step 201, first, dial connection is made to the National Health Insurance Federation (step 202), and the terminal on the side of the National Health Insurance Federation at that time If there is the National Health Insurance continuous reception data D2 such as the examination result / payment notification CSV and the correspondence document PDF in 30 (step 203), the national health insurance continuous reception data D2 obtained in this way is stored in the database 9. (See National Health Insurance Return Data 9e), the National Health Insurance Continuous Reception Completion Flag attached to the data D2 is stored in the National Health Insurance Continuous Reception Information Table TB2 that can be referred to from the establishment side terminal 20 (step 204).

  After that, an e-mail attached with the billing data D1 obtained in step 201 is transmitted to the terminal 30 such as the National Health Insurance Federation via the ISDN line (step 205), and then the dial is disconnected (step 206). .

  Through the processing up to this point, the billing data D1 transmitted in step 101 is transmitted to and saved at the terminal 30 of the National Health Insurance Federation or the like (see National Health Insurance Claim Data 9d), and at the same time the terminal 30 of the National Health Insurance Federation or the like. The National Health Insurance continuous reception data D2 generated in this way is sent to the intermediary device 10 and stored (see National Health Insurance return data 9e). Thus, as will be described later, each office 20 on the establishment side refers to the contents of the National Health Insurance Federation reception completion flag so that it is appropriately edited according to the requested search contents and the like. D2 can be browsed (see FIGS. 7 to 11).

  Finally, the National Health Insurance Federation transmission information generated in the above-described transmission process of the billing data D1 (information indicating the transmission status to which stage the transmission processing from the intermediary device 10 to the National Health Insurance Federation side terminal 30 has been completed) Is stored in the National Health Organization transmission information table TB3 that can be browsed from the business establishment side terminal 20. Therefore, it is possible to check the transmission status on each transmission side list screen on each of the business establishment side terminals 20 (step 102).

  Next, FIG. 3 shows a series of processes for acquiring National Health Insurance continuous reception data D2 (particularly, arrival confirmation or inspection acceptance data) that is always performed on the mediating apparatus 10 side. That is, as described above, the intermediary device 10 checks whether there is a transmission request command from the screen via a request table TB1 from the screen at a predetermined minute interval (for example, every 3 seconds). If there is no unprocessed request command, one establishment subject to automatic reception of arrival confirmation or inspection acceptance is extracted (step 208), dial connection is made to the National Health Insurance Federation (step 209), and at that time, the National Health Insurance Federation If there is National Health Insurance continuous reception data D2 including arrival confirmation or inspection acceptance data in the terminal 30 on the other side, etc., the arrival confirmation or inspection acceptance data is received (step 210), and the National Health Insurance continuous reception data D2 is the same as before. (Step 211), the dial disconnection process (step 212) is repeatedly executed.

  For this reason, since the National Health Insurance continuous reception information table TB2 always stores the National Health Insurance continuous reception data D2, the establishment side terminal 20 can check the transmission status on the transmission status list screen (step 103).

  Next, FIG. 4 shows a series of processing when the establishment side terminal 20 makes a reception request for National Health Insurance reception. That is, when the establishment side terminal 20 clicks a “Receive National Health Insurance Reception” button (not shown) on the transmission status list screen (step 104), a request command corresponding to the reception request is displayed from the screen. Stored in the request table TB1. Thereafter, in the same manner as before, various request commands stored in the request table from the screen are checked for existence at a minute time interval (for example, every 3 seconds), and the oldest request command that has not been processed is one. Obtained (step 213).

Here, assuming that the reception request command sent in step 104 is acquired (step 213), a dial connection is immediately made to the National Health Insurance Federation (step 214). If there is the National Health Insurance continuous reception data D2 such as the examination result / payment notification CSV and the correspondence document PDF in 30 (step 215), the national health insurance continuous reception data D2 obtained in this way is stored in the database 9. (See National Health Insurance return data 9e), the National Health Insurance consecutive reception completion flag attached to the data D2 is stored in the National Health Insurance continuous reception information table TB2 that can be referred to from the side terminal 20 such as a business establishment (step 216). Therefore, it is possible for each of the side terminals 20-1 to 20-n at each business office to check the National Health Insurance continuous reception data on the transmission status list screen (step 106).
The above description is merely browsing the National Health Insurance consecutive data D2, but browsing the other data itself (for example, various data 9a to 9i stored in the database 9) or various commands related to the data. The browsing of the data obtained as a result of performing the processing specified in (Extraction processing, reordering processing, writing processing, deletion processing, overwriting processing, etc.) is basically the same. For example, as will be described in detail later, when an unsupported return / pending case list request command or an error case list request command arrives from the side terminal 20 such as an office, execution of processing corresponding to those request commands is executed. The browsing data obtained by the above is processed into predetermined display data, and then returned to the side terminal 20 such as the office that is the command request source. It should be noted that general processing (search and extraction processing, rearrangement processing, writing processing, deletion processing, overwriting processing, etc.) in this type of server is well known from various documents, and thus detailed description thereof is omitted.

  Next, FIG. 5 shows an explanatory diagram of processing for realizing the first corresponding state flag control function which is the main part of the present invention. In the figure, when the care benefit billing data is transmitted at the terminal 20 of the service establishment (step 301), the billing data transmitted in this way is the mediation described with reference to FIGS. The data is sent to the terminal 30 on the side of the National Health Insurance Federation or the like via the transmission / reception relay function of the device 10, and the terminal 30 on the side of the National Health Insurance Federation or the like performs a predetermined reception process (Step 302) and an examination process (Step 303). Is executed. Here, if it is recognized as “return” (step 304) or “hold” (step 305), the NPO terminal 30 transmits the return / hold data D11. The return / holding data D11 transmitted in this way is sent to the terminals 20-1 to 20-n on the service establishment side via the transmission / reception relay function of the intermediary device 10.

  At this time, in the intermediary device 10, each time return / holding data related to any nursing care benefit claim request is received from the terminal 30 of the National Health Insurance Federation or the like, the response status of the nursing care benefit claim related to the return / holding data The flag is registered as “unsupported” (step 315), and then, regarding the nursing care benefit billing project, re-billing data arrives from the terminal 20 on the nursing care facility side, or the terminal on the side of the National Health Insurance Federation or the like 30 waits for a re-examination decision notice D13 to arrive.

  On the other hand, on the terminal 20 side of the service establishment, after confirming the contents of the return / holding data D11 (step 306), if it is an error, after performing a predetermined correction process (step 307), re-billing Processing is performed (step 308), and re-billing data D12 is transmitted.

  The reclaim data D12 transmitted in this way is sent to the terminal 30 such as the National Health Insurance Federation through the transmission / reception relay function of the intermediary device 10. At this time, as described above, the intermediary device 10 side waits for the arrival of the reclaim data D12 because it waits for the arrival of the reclaim data D12 with respect to the nursing care benefit billing project related to “return”. Thus, the “unsupported” registration of the response status flag of the nursing care benefit claim claim is automatically cleared (step 316).

  On the other hand, if it is determined in the confirmation process (step 306) that there is no error in the data, the service establishment side makes a reexamination petition to the National Health Insurance Federation terminal side separately by a predetermined communication means such as a paper medium ( Step 309). Then, after this is received and processed at the terminal 30 such as the National Health Insurance Federation (step 311), the examination is performed again (step 312), and when this is accepted (step 313), the reexamination decision notification D13 Is sent. The re-examination decision notice D13 transmitted in this way is sent to the terminal 20 on the service establishment side via the transmission / reception relay function of the intermediary device and confirmed (step 314).

  At this time, since the intermediary device 10 is in a state of waiting for the reexamination decision notification D13 to arrive from the terminal 30 such as the National Health Insurance Federation, it waits for the arrival of the reexamination decision notification D13, The “unsupported” registration of the flag is automatically cleared (step 317).

  On the other hand, if the result of confirming the return / holding data D11 (step 306) is recognized as “hold” due to an error in the benefit management slip, the benefit management slip is transferred from the service establishment to the related support establishment. When a correction request is made, and in response to the correction of the benefit management slip on the support establishment side (step 310), this is accepted by the National Health Insurance Federation or the like through a predetermined communication means such as a paper medium. Processed (step 311). Thereafter, the result of the examination (step 312) is accepted in the same manner as in the case of re-billing, and when this is accepted (step 313), the re-examination decision notice D13 is issued in the same manner. The re-examination decision notification D13 issued in this way is transmitted to the service establishment side via the transmission / reception relay function of the intermediary device, and this is confirmed (step 314).

  On the other hand, at this time, since the intermediary device 10 is in a state of waiting for the arrival of the reexamination decision notification D13 from the terminal 30 such as the National Health Insurance Federation, it waits for the arrival of the reexamination decision notification D13. The “unsupported” registration of the response status flag of the nursing care benefit claim claim is automatically cleared (step 317).

  In this way, in the intermediary device 10, each time return / holding data D11 relating to any nursing care benefit claiming matter arrives from the terminal 30 of the National Health Insurance Federation or the like, the nursing care benefit claim relating to the return / holding data D11 is received. The case status flag of the case is registered as “Unsupported”, and thereafter, the reclaim data D12 arrives from the terminal 20 on the side of the nursing care establishment or the like, or the side of the National Health Insurance Federation etc. Wait for one of the reexamination decision notices D13 to arrive from the terminal 30, wait for either the reclaim data D12 or the reexamination decision notice D13, It has a first corresponding state flag control function for automatically deleting the “unsupported” registration of the state flag.

  For this reason, the contents of the response status flag provided for each nursing care benefit billing case are re-billing data resulting from some response to the nursing care benefit billing case after the return / hold data D11 arrives. “Unsupported” only until D12 or the reexamination decision notice D13 arrives. Search using this “unsupported” registration as a key and other site units or site group units. By executing the process, it is possible to accurately extract the nursing care benefit billing cases that are currently "not supported". For example, if this extracted case is displayed as a list if necessary, It is possible to accurately notify the user of only the nursing care benefit request project in the state of “”.

  Next, FIG. 7 is an explanatory diagram showing a display example of an unsupported return / pending case list (entire) for each business establishment, FIG. 8 is an enlarged view of the list (left side portion), and FIG. Enlarged views are shown in FIG. 9, respectively.

  Note that the intermediary device 10 is searched using “unsupported” in the return / holding correspondence status flag as a key in response to a request for viewing an unsupported item for return / holding disposal coming from the terminal 20 on the care establishment side. A first browsing data generation and creation function is included that generates browsing data processed to display a list of the long-term care benefit cost claim cases and sends it to the terminal 20 on the nursing care facility side that is the request source. ing. Note that the specific processing necessary to realize such a function is merely a database search process and a browsing permissible process in the server. There seems to be no hindrance to its implementation.

  More specifically, in the examples of FIG. 7 to FIG. 9, after narrowing down only those belonging to a specific establishment from all the long-term care benefit request cases stored in the database management unit 9, Only those corresponding to “unsupported” in the corresponding status flag are extracted.

  The list display shown in FIG. 7 to FIG. 9 is based on the browsing data sent from the intermediary device to the terminal 20 on the side of the nursing care establishment or the like, and is displayed on the terminal 20 on the side of the nursing care establishment or the like. It shows what is displayed on the device screen.

  In this list display, six display lines extending in the horizontal direction each indicate one independent billing item, and each display line has 16 display fields. In other words, in the display column from the left, “the latest examination date”, “service provision date”, “insurer number / insurer name”, “insured person number / user name”, “ “Type”, “Service Type”, “Number of Units / Specific Residents / Care Costs”, “Amount / Specified Residents / Care Costs”, “Reason”, “Contents”, “Remarks”, “ “Billing presence / absence”, “returning presence / absence of specific date”, “determination (system)”, “determination (overall)”, and “change / login ID” are assigned.

  Of course, all the cases described in each of the display columns of these six lines are “not supported”. The intermediary device 10 has a function of determining the status of each billing item by the system in accordance with a predetermined determination criterion. This determination result is displayed in the “determination (system)” column.

  In the initial state of the list display, as long as all cases have a “return” or “hold” certification, the determination result by the system is “need confirmation” for all cases. As described above, when “required” is displayed as a determination result in the “determination (system)” column, the entire display line is in a specific display state with a predetermined color and brightness. Specifically, in this example, the entire display line is displayed in yellow, which is a dangerous color, to alert the operator.

  Therefore, the operator needs to confirm the cause of “return” or “hold” one by one for the display line colored yellow. If the cause is an error in the benefits management slip, it is necessary to correct the benefits management slip through the support office.

  In the “determination (overall)” column, a pull-down menu type input operation unit is displayed. The initial display state of this “determination (overall)” column is linked to the display state of the “determination (system)” column. That is, if the display state of the “determination (system)” column is “confirmation required”, the initial display state of the “determination (overall)” column is also “confirmation required”. If you manually change the display contents of this “judgment (overall)” field from “confirmation required” to “deletion complete”, the “confirmation required” that is displayed in the “judgment (system)” field will be erased. The specific display state (colored yellow) of the entire display line is canceled and the initial display state is restored to white display.

  In addition, in the “change / login ID” column, a login ID assigned to the person who performed the change operation from “confirmation required” to “erasure completion” is displayed. As a result, if the display content in the “Judgment (system)” column is manually changed from “Confirmation required” to “Erase completion”, it is possible to clearly keep a record of who performed this. This makes it possible to prevent an unauthorized operation from occurring. In addition, if you manually change from “Confirmation required” to “Erase completed” in this way, the corresponding status flag “Unsupported” registration will be erased. Even if it searches, such a matter will no longer be extracted.

  FIG. 10 is an explanatory diagram showing a display example of a list of unsupported return / holding cases (whole) for each group. The difference in the list display is that, from all the cases, only one establishment group belonging to a specific corporation is narrowed down, and unsupported cases are extracted within the narrowed establishment group. The content is the same as the list display shown in FIGS. Therefore, the description about the point which overlaps with the list display for every establishment is abbreviate | omitted.

  Next, an explanatory diagram of processing for realizing the second correspondence state flag control function is shown in FIG. In this figure, when the billing data is transmitted in any of the nursing care benefit billing cases (step 401), the billing data transmitted in this way is the mediation apparatus described above with reference to FIGS. 10 is sent to the terminal 30 of the National Health Insurance Federation or the like through the transmission / reception relay function of 10. On the side of the National Health Insurance Federation or the like, after performing a predetermined reception process (step 402), an examination is performed (step 403), and if it is accepted (step 404), predetermined data is returned. The data thus returned is sent to the terminal 20 on the service establishment side via the transmission / reception relay function of the intermediary device 10. Here, if any error is found (step 405), an error application (step 406) by the insurer (local government) is made directly to the National Health Insurance Federation through a paper medium, and this is accepted ( Step 407) is examined (Step 408), and when this is accepted (Step 409), an error determination notice D21 is issued. The error determination notice D21 issued in this way is sent to the terminal 20 on the service establishment side via the transmission / reception relay function of the mediating apparatus 10.

  On the other hand, each time the intermediary device 10 receives an error determination notification D21 relating to any of the nursing care benefit request cases from the terminal 30 of the National Health Insurance Federation or the like, the care benefit expense claim case relating to the error determination notification D21 is received. Is registered as “unsupported”, and thereafter, with respect to the nursing care benefit billing case, it is set to wait for the reclaim data D22 to arrive from the terminal 20 on the nursing care establishment side. Therefore, after the error determination notification D21 arrives, the response status flag of the care benefit billing case is registered as “not supported” (step 417).

  On the other hand, after confirming the error determination notice D21 (step 410), after making necessary corrections (step 411) and performing re-billing processing (step 413), the terminal 20 on the service establishment side re-bills. Data D22 is issued. The re-billing data D22 is sent to the terminal 30 on the side of the National Health Insurance Federation through the transmission / reception relay function of the mediating apparatus 10, and after a predetermined reception process (step 414), it goes through examination (step 415). Are received (step 416).

  On the other hand, on the side of the intermediary device 10, after registering the response status flag as “unsupported”, the intermediary device 10 waits for the re-billing data D 22 to arrive from the terminal 20 on the nursing care establishment side regarding the nursing care benefit cost claiming project, It waits for the re-billing data D22 to arrive, and the system is configured to automatically clear the “unsupported” registration of the corresponding status flag of the nursing care benefit billing case. Therefore, after the re-billing data D22 arrives at the intermediary device 10, the “unsupported” registration of the response status flag is automatically cleared (step 412).

  As described above, in the intermediary device 10, every time an error determination notification regarding any of the nursing care benefit request cases arrives from the terminal 30 on the side of the National Health Insurance Federation or the like, the status flag of the care benefit expense request case regarding the error determination notification Is registered as “unsupported”, and thereafter, for the nursing care benefit cost claiming case, it waits for the reclaiming data D22 from the terminal 20 on the nursing care establishment side, and waits for the reclaiming data D22 to arrive. , A second response status flag control function for automatically deleting the “not supported” registration of the response status flag of the care benefit billing case is provided.

  Furthermore, although not shown in the figure, the intermediary device 10 is keyed with “unsupported” in the error data response status flag in response to a request for browsing an unsupported error data from a terminal such as a care establishment. Second browsing data that is generated as browsing data that is processed so as to display a list of non-error-supporting nursing care benefit billing cases that are searched for and sent to the terminal 20 on the nursing care facility side that is the request source Includes a send function.

  FIG. 11 shows an explanatory diagram showing a display example of a list of error cases (whole) for each business office. The case list shown in the figure is displayed on the screen of the terminal on the side of the nursing care establishment or the like as a result of the operation of the second browsing data generation and transmission function described above.

  Even in this example, each display column extending in the horizontal direction corresponds to an independent case. Each display line is provided with 14 item fields. In this example, such items include “Reception date”, “Service provision date”, “Insurer number / insurer name”, “Insured number / user name”, “ “Service type”, “Number of units / specific residents / care expenses, etc.”, “Amount / specific residents / care expenses, etc.”, “Reason code”, “Error reason”, “Availability of specified date”, “ “Error of specific year / month”, “determination (system)”, “determination (overall)”, and “change / login ID” are assigned. The meanings of these item columns are the same as those described above with reference to FIGS. Therefore, duplicate description is omitted. That is, in the figure, two cases of “error” disposal have occurred, and the display lines corresponding to these two cases are colored yellow. The contents of the error are clarified by the error code and the explanatory text, and the display of the “determination (system)” column and the “determination (overall) column” is both “confirmation required”. On the other hand, in this state, after confirming the reason for the “error” disposal, the display in the “judgment (system)” column will be erased if the “judgment (overall)” column display is manually switched to “deletion complete”. In addition, the entire display line (horizontal line 1) is returned from yellow to white. In addition, in the “change login ID” column, a login ID related to the person who performed the manual operation is displayed.

  Note that the display states of FIGS. 7 to 10 described above mainly show the case where the “pending” disposal occurs, but when the “return” disposal occurs, the display of the “return presence / absence” column is displayed. In addition to switching from “No” to “Yes”, the “Judgment (system)” column display also changes to “Confirmation Required”, and the “Judgment (Overall)” column also changes to “Confirmation Required”. (Horizontal one line) is displayed in yellow. On the other hand, after confirming the reason for the “return” disposal in this state, if the display in the “judgment (overall)” column is manually switched to “erasure complete”, the display in the “return presence / absence” column will change from “present” In addition to switching to “none”, the display of the “determination (system)” column is also deleted, and the entire display line (horizontal line) is returned from yellow to white. In addition, in the “change login ID” column, a login ID related to the person who performed the manual operation is displayed.

  According to the present invention, in the intermediary device for this kind of nursing care benefit request procedure, if a browsing request regarding an unsupported item for return / holding is made at the terminal of the nursing care facility side, a true message is displayed on the screen of the terminal. A list of claims for nursing care benefits related to “Unsupported” is displayed. By prompting the user to respond to the matter, the claims for nursing care benefits that have been returned or put on hold are left unattended for a long time. It is possible to prevent a situation in which receivables are generated.

1 Transmission / reception relay function 2 Progress stage management function for billing procedures, etc. 3 Pre-transmission check function for transmission information 4 First correspondence status flag control function 5 Billing omission prevention function (warning mail distribution function)
6 Second correspondence status flag control function 7 Data management function 8 Corporate headquarters management support function 9 Database management section
9a Member Master 9b Office Master 9c Office Group Master 9d National Health Insurance Claim Data 9e National Health Insurance Return Data 9f Claim Management Data (Return)
9g Claim management data (billing)
9h Error data (return)
9i Error data (billing)
10 Intermediary device 20-1 to 20-n Nursing care facility side terminal 30 National Health Insurance Federation side terminal D11 Return / hold data D12 Reclaim data D13 Reexamination decision notice D21 Error decision notice D22 Reclaim data

Claims (6)

A device that is interposed between a terminal on the side of a nursing care facility that makes a claim for care costs and a terminal on the side of the National Health Insurance Federation or the like that receives a claim for care costs,
It is connected with the terminal of the nursing care establishment side via a network system, and is connected with a terminal of the National Health Insurance Federation etc. via an ISDN or other network system, and a predetermined transmission / reception relay function Is realized,
The predetermined transmission / reception relay function is
Sending and storing information coming from the terminal of the nursing care establishment side to the terminal of the side of the National Health Insurance Federation and receiving and saving information sent from the terminal of the side of the National Health Insurance Federation, In response to a browsing request from the terminal on the nursing care facility side, the function is to send browsing data processed for browsing to the terminal on the nursing care facility side that is the request source. ,
The device is
Each time the return / holding data related to any nursing care benefit billing case comes from the terminal of the National Health Insurance Federation, etc., the corresponding status flag of the nursing care benefit billing case related to the return / holding data is registered as “unsupported” Then, regarding the long-term care benefit billing project, either the re-billing data comes from the terminal of the nursing care establishment side, or the re-examination decision notification comes from the terminal of the National Health Insurance or other side. A first response that waits for either the re-billing data or the re-examination decision notification to arrive, and automatically clears the “unsupported” registration of the corresponding status flag of the nursing care benefit claim request A state flag control function, and the transmission / reception relay function includes:
In response to a request for viewing an unsupported return / pending disposal response that comes from the terminal on the nursing care facility side, a nursing care benefit claim claim that has been searched using “unsupported” in the return / holding correspondence status flag as a key. Including a first browsing data generation / sending function that generates browsing data processed to be displayed in a list and sends it to a terminal on the side of the care establishment that is the request source,
An intermediary device for a procedure for claiming long-term care benefits. The device is
Each time an error decision notification related to any of the nursing care benefit billing cases arrives from the terminal of the National Health Insurance Federation or the like, the corresponding status flag of the care benefit expense claim case relating to the error decision notification is registered as `` not supported '' Thereafter, regarding the long-term care benefit billing case, the system waits for re-billing data from the terminal on the long-term care establishment side, waits for the re-billing data to arrive, A second correspondence status flag control function that automatically erases the “unsupported” registration of the flag, and the transmission / reception relay function includes:
In response to a request for browsing non-correspondence of error data coming from the terminal of the nursing care establishment side, an error non-corresponding care benefit billing case searched using “unsupported” in the correspondence status flag of the error data as a key It further includes a second browsing data generation / sending function that generates browsing data processed to be displayed in a list and sends it to the terminal of the nursing care facility that is the request source.
The intermediary device for the nursing care benefit billing procedure according to claim 1. In the list display of the long-term care benefit billing cases, a system determination result display field for automatically displaying a judgment result obtained by the system judging the status of each billing case against a predetermined judgment criterion is displayed for each billing case. It is provided for each line, and when a display equivalent to “confirmation required” is performed in the determination result display field, the entire billing matter display line related to the “confirmation necessary” is in a specific display state with a predetermined color and brightness. The
The intermediary device for a nursing care benefit billing procedure according to claim 1 or 2. In the list display of the long-term care benefit billing cases, the comprehensive judgment result display column for displaying the judgment result obtained by the operator comprehensively judging the status of each billing case by manual operation in the menu method is displayed for each billing matter. It is provided for each line, and the initial display state of the comprehensive determination result display column is linked with the display state of the system determination result display column, while when this is changed to a display corresponding to “consumption completed” by manual operation, The specific display state related to the billing matter display line is canceled,
The intermediary device for a nursing care benefit billing procedure according to claim 3. When the initial display state of the comprehensive judgment result display field is changed to a display corresponding to “consumption completed” by manual operation, the “unsupported” registration of the response status flag of the nursing care benefit billing case related to the billing case display line is also released To be
The intermediary device for a nursing care benefit billing procedure according to claim 4. In the list display of the long-term care benefit billing cases, a change login ID display field is provided for each billing matter display line, and the initial display state of the comprehensive judgment result display field is equivalent to “consumption completed” by manual operation. When the display is changed, the login ID of the user who performed the change operation is displayed in the changed login ID display field.
The intermediary device for a nursing care benefit request procedure according to claim 4 or 5.

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